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The woman, whose identity was withheld by New Scientist, and her husband sought the help of John Zhang, a doctor from the New Hope Fertility Center in New York City to have a baby that would be genetically related to them but would not carry the inherited disease.

World’s first baby born from 3-parent technique: report More Miami (AFP) – The world’s first baby has been born using a controversial new technique by US scientists to include DNA from three parents in the embryo, said a report. The baby boy was born five months ago in Mexico to Jordanian parents, and is healthy and doing well, said the report in New Scientist magazine, described as an “exclusive.” The boy’s mother carried genes for a disorder known as Leigh Syndrome, a fatal nervous system disorder whic

8 Tools to Get Control of your Anxiety Looking at repeating patterns (fractals) is proven to relieve anxiety. See below for more details. It’s time to learn tangible tools to control your anxiety, so that it stops controlling you! Feeling anxious is uncomfortable, painful and difficult to manage in every which way. Your body is on overdrive. You can’t think straight. Everything feels like it’s crashing down at any moment and you just can’t stop the chaos. The truth is that anxiety is a symptom of some de

Led by Diane Cote, LCSW, 415.366.8830, dianecotelcsw@gmail.comThis “Leader-Led RESOLVE Support Group” is open to women with a diagnosis of infertility.

Topics include; IVF cycling, repeat miscarriage, third party reproduction, secondary infertility and integrated healing approaches. We will discuss the impact infertility has on your close relationships, your career, and social situations.

We will work with challenging feelings and how treatment impacts your mind and body.

Participants and leader serve as resources to each other in the practical matters of navigating clinics and agencies.

I will lead participants through mindfulness-based techniques that can be used for coping with ongoing, day-to-day, stress.

A strong emphasis on self-renewal, self-care and self-compassion will be at the heart of the group, which will be conducted in a safe and confidential setting.

We know that women outnumber men significantly when it comes to mental illness diagnosis — they’re twice as likely to be found to have depression and anxiety disorders — but the reasons why are less clear.

New research from the University of Montreal, published in the journal Psychoneuroendocrinology, points towards greater emotional reactivity in women as one possible explanation for gender differences in mental illness.

For the study, blood samples were taken from 46 healthy participants, 25 women and 21 men, to measure their hormone levels. The participants were also asked to say how feminine or masculine they think they are. Then they looked at a series of images and said whether they evoked positive, negative or neutral emotions, all while the researchers scanned their brains.

The researchers found that the women expressed stronger emotional feelings towards the negative images they were shown (as sampled below) than the men did, a difference apparently rooted in brain function, hormones and social norms.

INTERNATIONAL AFFECTIVE PICTURES SYSTEM

In both the men and women, two different brain areas were activated when they viewed the negative images: The dorsomedial prefrontal cortex, which is involved in reasoning and action, and the amygdala, which is involved in threat perception and fear processing.

In women, there was a relatively weak connection between the two brain regions. In men, the connection was stronger.”A stronger connection between these areas in men suggests they have a more analytical than emotional approach when dealing with negative emotions,” Dr. Stéphane Potvin, a professor of psychiatry and one of the study’s authors, said in a written statement. The strong connection may also be due to testosterone activity in the male brain. Higher levels of testosterone were linked with decreased sensitivity to the images.

“This suggests that men are more in an active mode when experiencing negative emotions, whereas women have a more purely affective brain response,” Potvin said.

But these differences aren’t just the result of biological factors. Self-reported levels of femininity or masculinity also played a role in the connection between the two brain areas, suggesting that gendered cultural norms can affect emotional responses.

Higher levels of “feminine traits” in both women and men were linked to a greater emotional reactivity to the negative images.

While the findings don’t necessarily tell the full story of why more women than men are diagnosed with mental illness, Potvin noted that they offer “important clues that will need to be tested in individuals who are at risk of suffering from anxiety or mood disorders.”

Interesting perspective on egg freezing…
Last fall, I went to an egg freezing cocktail hour. The downstairs bar of the glossy SoHo hotel was thronged with women in heels and sleek business attire. Club music thumped, cameras flashed, and I narrowly missed being hit by a videographer angling a tripod over the crowd. The evening was hosted by Eggbanxx, a startup that sells financing for egg freezing, framed as fertility insurance for the forward-thinking urban professional woman.

At the bar, where they were serving up free “Banxxtini” cocktails, I spoke with a 27-year-old who was “95 percent sure” she would freeze her eggs and a 36-year-old data scientist who claimed to be “skeptical.” Together, we filed into a screening room adjoining the bar, where three New York-area endocrinologists lectured us on a new technique that, they claimed, could freeze our reproductive chances in time. Female fertility declines sharply at 37, due to a decline in the quantity and quality of eggs. But when women use fresh eggs from a young donor in an in vitro fertilization (IVF) cycle—a process in which fresh eggs are harvested from the donor, fertilized, and transferred to the uterus—live birth rates rise across ages to 56 percent.1 Now, thanks to a new freezing technology, women could become their own future egg donors, rather than relying on the fresh eggs of another, younger donor. “It’s good to be empowered as a woman,” beamed Janelle Luk, a doctor at Neway Fertility.

Nicole Noyes of the NYU Fertility Center, lean and intense, spoke energetically about egg freezing, a field in which she was an early leader. She began with a reassuring screenshot of her recent study finding no higher risk of birth defects among 900 children born from frozen eggs.2 Her clinic’s results seemed incredible: If a woman freezes her eggs at 35, Noyes told us, and uses them at, say, 43, she has a 50 percent chance at a live birth from one IVF cycle. Compare that to her unaided chances of conception (using IVF or naturally) at age 43: 5 percent each cycle. If she freezes her eggs later, at 38, her success rate for one IVF cycle dips to 37 percent. According to Noyes, success is determined by the age at which you froze the eggs. “31 is as long as I’d wait,” she told one questioner in a swarm of audience members, many still clutching purple cartons of popcorn, after the presentation. I had lost sight of the 27-year-old, but I spotted the data scientist hurrying up an aisle to sign up.

And so, to my surprise, I found myself considering egg freezing again, based on a biomedical marketing event dressed up as a girls’ night out in Sex and the City.

Interview with Diane Cote, LCSW
Mindfulness Based Psychotherapy, Infertility Counseling & Reproductive Health
Offices in San Mateo and San Francisco, California
September 2012

Bio: Diane Cote is a psychotherapist specializing in infertility counseling and related reproductive health issues. She has been in private practice for over 15 years. Her treatment orientations include psychodynamic, mindfulness based cognitive-behavioral therapy, and mindfulness based practices such as yoga, guided imagery and breath work. She received her Masters degree in Clinical Social Work from Boston University. She has completed post graduate training through the American Society for Reproductive Medicine on areas specific to infertility counseling and numerous issues related to reproductive health including ethical issues and mind body influences on fertility. She has studied at the Domar Center for Mind-Body Health, the Esalen Institute and the EMDR (Eye Movement Desensitization and Reprocessing) Institute. She is also a registered Yoga teacher (RYT-200) and offers yoga for fertility workshops for women and couples with an emphasis on self-care and mindfulness based practices. Diane has a twenty-five year yoga and mediation practice.

KP: You are an expert in reproductive health & fertility counseling. Could you briefly explain what that is?

Diane: A clinical diagnosis of infertility is defined as trying to conceive over a 12 month period without success. Approximately 30% of the time it’s a female problem and 30% it’s a male problem. The remaining 40% percent is either a problem related to both the male and female, or what is known as “unexplained infertility.”

I work with couples who have reached that one-year mark, (and well beyond), and have received a formal diagnosis of infertility from a reproductive endocrinologist. After failed attempts to conceive after one year, coupled with an infertility diagnosis, clients start to experience more serious, emotional symptoms. That’s where I come in as a fertility counselor.

Anxiety, depression, and relationship challenges are common with infertility. My first meeting includes an overall client assessment. The focus is primarily on the current issues surrounding infertility, however, past losses usually get triggered once people are facing infertility. Part of my job is to help people see this connection and understand how it might be impacting them in the present.

2.) KP: Can you talk a bit more about the “issues around fertility?”

Diane: New studies are revealing how psychologically traumatic infertility can be. One recent study found that for women, the emotional stress of receiving an infertility diagnosis is equal to the emotional stress of receiving a cancer diagnosis. It’s often underestimated.

Infertility is somewhat of a silent disease. There’s a lot of shame around it and a sense of overwhelming failure so people choose not to talk about it openly with friends and family. Then they become isolated and that’s not good for their mental health.

KP: That’s an amazing study suggesting that infertility can have the same emotional impact that a cancer diagnosis can have. I imagine most people would be surprised to hear that, so that’s useful information to have. The piece about it being a “silent disease” seems to make sense.

Diane: The other interesting study that has just come out is that women who have had a prolonged diagnosis of infertility start exhibiting symptoms of Post Traumatic Stress Disorder (PTSD). I see this in my patients. Most of my patients have been trying to conceive for at least 2 years and some even 4-6 years with no success of getting pregnant. They can become quite traumatized by repeated medical interventions that fail. They lose hope. They often have the characteristic PTSD symptoms of overwhelming anxiety, intrusive thoughts, nightmares, the inability to focus, and depression.

KP: So, you mentioned the emotional difficulties related to feelings of shame, the concept of the body failing and the possibility of past losses colluding with what’s happening in the present. Is there anything else you can share about why struggling with infertility can be so traumatic?

Diane: There are many reasons, and it’s fairly complex. Here is an example. I had patient who lost a parent at a fairly young age. Her worldview was fundamentally changed at the time of that loss. After repeated miscarriages the past loss of the parent is triggered. This stirs up the belief systems and mental models of “things just don’t work out for me, bad things happen to me, I’m never going have a healthy child, something is going to go wrong, etc.” This thinking leads to depression, anxiety and hopelessness. Even though she did eventually get pregnant on the third try, she worked very closely with me during the entire pregnancy. She was so terrified that she would have another miscarriage, have a special needs child, or experience a stillbirth. So, there was a lot of support given to her, and we discussed the past losses and how that was triggering her during her pregnancy. I also gave her practical tools such as guided imagery and relaxation breathing techniques. She reported that this had been extremely helpful.

Added to the complication of all that emotionality and past history, are the numerous hormones that women experience during pregnancy. The body is completely flooded with all kinds of raging hormones. So it’s very common for women to experience intense mood swings and lots of tearfulness during pregnancy. That makes it even more challenging.

Then there are so many of my women patients who see everyone around them becoming pregnant so easily. Their entire peer group is pregnant, about to give birth, have an infant or toddler or moving on to the second pregnancy or having the second baby. It is extremely painful for these women to witness this, be invited to numerous baby showers, etc. They often feel like an outsider and on top of it, they have to field intrusive questions about their own plans for a family or how things are going with their infertility treatments. This again causes them to isolate leading to deeper states of depression. There are some who feel intense anger and envy, a sense of injustice and unfairness in the world. The “why me?” factor.

3.) KP: In that I heard that in addition to working on the psychological pieces, at times you would give guidance or recommendations regarding medical treatment options? I imagine those decisions are complex. The patients are obviously working with their physicians, but I imagine that they look to you as well to process their thoughts and feelings about which way to go?

Diane: I always say right up front, I’m not a Reproductive Endocrinologist (RE). I will disclose here that I had my own, very long journey with infertility and I may share that with a patient depending on where they are in their own process.

Again, I let them know that I’m not a medical doctor, but I provide psycho-education and consultation when necessary. Depending on their circumstance, it can be pretty obvious that they’ll need a higher level of intervention, so I might discuss the range of options out there and encourage them to discuss them with their RE.
I will sometimes explain to them what IVF (in-vitro fertilization) is and how they would go about pursuing that option. So, I’m able to give them very specific information about that process and also recommend several clinics in their local area.

I try to be a resource, to provide useful information, including alternatives for them to think about. I try to answer their questions and if I can’t, I try to lead them in the right direction. But, ultimately, decisions about which interventions to pursue have to be made with their partner and their doctor.

KP: Sounds like that would be valuable to provide that concrete information. Having more information tends to help lower anxiety to some extent. It sounds like you are well versed in this area with not only your professional experience as an infertility counselor, but also having had your own personal experience with infertility.

Diane: Yes, and it’s an interesting process because people start at one place and often end up in another. They might say, “if I don’t get pregnant in the next year, then we’ll really think about not having children or maybe we’ll adopt.” Unfortunately, on a side note, adoption has become more and more difficult and expensive. There are fewer children to adopt in the U.S. so it’s competitive and can take quite a long time. Additionally, the international adoption process has become very challenging and limited.

Or, they might say, “I’ll never do in-vitro fertilization” and then two years later, they find themselves saying, ok, we want to try in-vitro. Then if in-vitro doesn’t work and they need more intervention, they may initially say no way to a surrogate or egg donor, but then find themselves considering those options after all else has failed. It’s a very interesting journey.

Unfortunately, people experience more and more failure around trying to get pregnant. They find themselves making choices that they thought they wouldn’t make. But, having a child becomes so important to them. I help guide them along that process as well.

KP: So, some people may initially think that they would never consider other options, but as the process goes on, they may become more open to trying further intervention, as they realize how much they want to have a child and be a parent.

4.) KP: I imagine that here in the bay area, where there’s so much diversity, that you work with couples from various cultural backgrounds. How have you seen culture impact this whole process when it comes to dealing with infertility?

Diane: I see people from various cultural backgrounds. I don’t want to stereotype anyone, but there are certain cultures that value having children at a young age, often delaying education. They typically don’t have problems with infertility. Then there are cultures that delay having children in order to achieve a higher degree of education and career and financial success. Delays in starting a family can also be due to trying to find the right partner. This can sometimes take quite a long time. And then, by the time they feel “ready” to start a family, they may be in their late 30’s or early 40’s and then there are difficulties. Another thing I see are people who have had a divorce and are on the second marriage. They finally figured out the partner situation and are ready to have a child but they are often older which is problematic.

The mental health community is trying to influence the medical community, specifically, Ob/Gyn’s, to educate women about the realities of their fertility. The fact is that after 35 years of age, fertility takes a significant drop. Many women don’t know that. Unfortunately, the media has really done a disservice to women because there are movie stars all over magazines that are 45+ years old having babies. What they don’t reveal is that they are using an egg donor and they’re not being open about that, so it’s sending women the wrong message. Women are influenced by this and mistakenly think they can wait until they’re 42 or 44, to easily get pregnant. Again, fertility dips after 35, and after 40 it takes a very big dip.

KP: I’m glad you brought up the piece about the significantly diminished childbearing after 35. That’s important information to highlight. It seems that, generally speaking, in the dominant culture of white middle class America, there is this you-can-have-it-all-ethos, where people end up delaying the family building part. And, the media bias certainly doesn’t help matters, as you said. Of course, there’s nothing wrong with people trying to build families later in life, but like you said, it’s important for all to be aware of the childbearing odds as one ages.

5.) KP: While you provide general fertility counseling, you are also known as a specialist in “third party reproduction” in particular. Can you talk about that?

Diane: Third party reproduction is when you use a gamete donor or a surrogate in order to achieve a pregnancy. In the case of gamete donation, many women (and couples), have a strong desire to experience pregnancy. Not all women. Some women are fine with not having that experience, but many women feel it’s central to their experience of having a child. They want to see the pregnancy all the way through, they want to ensure great prenatal health. They want to give birth and nurse.

Egg donation has been around since 1983 – that was when the first successful egg donation took place. But, it’s only become more known and publicized in the last 5-10 years. It had been more of a closeted experience, much like sperm donation had been for many, many years. Way back when, when the King wasn’t able to produce, the Queen would be inseminated with somebody else’s sperm and nobody would be the wiser. So, while sperm donation has been going on for a long time, the technology for successful egg donation is relatively new. The cycles of the “intended mother” and the egg donor are simultaneously coordinated. The donor is then given stimulation drugs and the eggs are harvested from her and then inseminated with the sperm of the intended mother’s partner. Embryos are then created through in-vitro fertilization. Then, those embryos are transferred back to what is defined as the “biological mother.”

The DNA is from the egg of the donor, but once the embryos are transferred back into the intended mother, she is technically defined as the “biological mother” because she will be giving birth to a child…hopefully, if all goes well.

It can be quite complicated emotionally because people have to come to terms with releasing or giving up their own genetic material. And, that is a very primal instinct; so people hold on to that dearly. So, part of my process, in working with women who need to make a choice to go to donor if they are ever going to be pregnant, is helping them grieve the loss of their genetics. Also, to explore what it really means to use a donor to them and to help them create a new and healthy story around that.

There is the educational piece around what it really means to be a parent. The goal is to be a parent and parenting and family is about attachment and bonding. The genetics really aren’t as important as people often believe that they are.

I want to also note that gay men have really opened up this whole arena, because in the last 10-15 years, many gay male couples have used a surrogate, used an egg donor to have a child. So, the entire process has become much more open based on the exposure that the gay male community has given it. It’s become accepted in that community, and it’s kind of spilled over into the heterosexual community that this is an option and there is no shame around it. It’s not inexpensive, but it can be done.

I also work with people on how to talk with their young children about their conception and to family members about this process. In the mental health community, we’re very pro disclosure. We believe, as you know, that secrets are not good in families, so a lot of my work goes around helping people feel comfortable about this decision and not having shame around it. Not having shame when they talk to their young children in very basic ways about their conception, and introducing the fact that there was this third person (or more if using a surrogate) that helped us have you. Making it very much the fabric of their lives, their story.

When parents are comfortable and casual about discussing their children’s origins then the child will be comfortable and confident about where they came from and their story. That’s also another big piece. A lot of times when people do have a child through donation, they’ll come back to me and say, gee my child is 4 or 5 years old and I’m really struggling with how to talk to them about their conception. Then, we’ll work on that piece as well.

24:40

There is one caveat: if disclosure would harm the child in some way. Perhaps there’s a relative that isn’t stable and might say something inappropriate to the child, then maybe under those circumstances, you choose not to tell that relative or maybe you wait a while. There is some discernment required, if the potential exists, that the information may be misused in someway. But the general consensus in the mental health community is to tell often, tell early and be honest and relaxed about it.

KP: The openness, not being secretive – that’s great that you can facilitate that process. It’s certainly interesting to hear about the history about egg donation, that 3rd party reproduction has been going on for years, but people just don’t often talk about it. It does sound positive, however, that people are starting to be more open.

Diane: Yes, but we still have a long way to go. The San Francisco Bay Area is probably the most open place about these kinds of issues. I was at a conference a few years ago on the East Coast and it’s a very different mentality there. It tends to be driven somewhat regionally. We’ll see where it goes. My particular perspective is that it’s about your values. If you value honesty and integrity as a parent and a person and you believe your child has a right to know the truth about their origins, then that’s what you’re going to transmit.

6.) KP: Can you talk more about the specific tools you use when working with patients who are struggling with infertility?

Diane: Both in my psychotherapy practice and in my own life, I’m very pro mindfulness meditation, yoga and acupuncture. Combining interventions from the East and West. A lot of these practical tools, like mindfulness meditation, guided imagery, and breath work, I really encourage clients to cultivate a practice with these tools. I often get them started in my office, leading them through guided imagery and mindfulness meditation and then refer them to resources. I’m a yoga person. Anything that can relax the mind and the body. I’ll refer them to different yoga teachers and studios, to get them exposed to it so they can start to practice this feeling of relaxation, calming the mind, calming the intrusive thoughts. Of course, the more you practice, the more it becomes an autonomic response, where you can call it up in the most difficult situations.

Also, helping people connect with others who are in the same boat. I used to run groups, but I haven’t done one in a while; I’m thinking next year I may start leading one again. But, there are some really great support groups out there. Some of the groups are with independent clinicians. Some are led by RESOLVE – which is a national infertility organization that’s been around for 50 years. They have chapters all over the country and RESOLVE support groups are run by therapists (or peer led) in particular geographic locations. Support groups are fantastic for people with infertility diagnoses because the people in those groups really get it, like nobody else. So, I often will recommend that patients attend support groups.

Getting their partner in the room can also be quite helpful. Most times, the woman comes to me for help and after a while I might invite her partner to come for a session or two. This process can be very, very stressful on relationships. There’s the emotional stress and there is often great financial stress. These are couples that are generally pretty stable and happy, but often times the goal of getting pregnant and having a child takes over everything. I work to get them back on track, how to come together on goals and how to have fun again in the relationship.

Diane: I also want to add that I’m connected to a couple of great acupuncturists. Acupuncture is highly recommended for infertility. There have been some studies that show that acupuncture can improve pregnancy outcomes. A lot of times the acupuncturist and mental health people will send each other patients, which has been great. I work with a few acupuncturists that I refer patients to and they often refer their infertility patients who require counseling. We’re trying to help people by referring them back and forth.

KP: Acupuncture has applications in so many arenas, but I wasn’t aware of how it can help with infertility, that it’s been scientifically validated in that arena, so that’s good to know.

Diane: A lot of the big clinics also have an in-house acupuncturist. Right after an embryo transfer, they’ll do an acupuncture treatment session right there at the clinic. It has proven to increase pregnancy outcomes for in-vitro fertilization.

KP: On a side note, do you find that most people are open to the suggestion of acupuncture or does that freak people out at all :-)?

Diane: Of course in the San Francisco Bay Area, many people have already tried it. For some people it is scary, but honestly, by the time people are coming to counseling, they are desperate to try anything. So, if it means sticking needles in them, they will try it. There are acupuncturists who specialize only in fertility – they study how acupuncture can increase fertility and they’re really good at what they do.

KP: That makes sense. I’m really glad you brought up the piece about support groups. That seems like connecting people to others who are going a similar process could be incredibly helpful.

Diane: Yes, and I should also add that the support groups are starting to bifurcate, where you have “general infertility” groups for people who are just finding out, who have recently received the diagnosis of infertility. Then there are egg donor support groups, for people who are trying to figure out if they want to go to donor and/or people who have already made that decision. Those who are going with egg donor can speak to their experience about that process and help others who are trying to make up their mind about whether to go in that direction.

33:00 – PART 2

7.) KP: What is the greatest barrier to individuals or couples pursuing fertility counseling?

Diane: There are several reasons. A new study has come out that shows that IVF clinics don’t suggest it or provide referrals. A lot of the big clinics have a mental health professional on staff, so sometimes that person will do an assessment and then refer people out to see a clinician on an ongoing basis, but it’s not as robust as I’d like to see it.

The other situation involves people who have never had a need to do any kind of counseling. They are high functioning people often times, who are relatively emotionally stable, so it’s not even in their consciousness that they might need some help, along with where and how to get it.

The other barrier can be cost. Infertility treatments are expensive, so counseling is one more thing that they have to pay for and sometimes they feel that they have to cut a corner somewhere and they won’t pay for the counseling because they feel they need to use that money for the medical interventions.

I also think that with specific cultures there’s a lot of shame and guilt. This is a generalization, but sometimes in Asian cultures, for example, it can be very shameful to go outside of your family or community to seek help. So, that can sometimes be a barrier as well.

KP: The cultural piece is understandable. And, what you said about how there are people where the idea of counseling has never really crossed their mind, so they’re not going to be considering it. Continuing to educate people seems so important because fertility counseling can provide a lot of assistance, guidance and healing. As you said earlier, contending with infertility can be quite a traumatizing experience. Navigating it more in isolation seems so much harder than with the assistance of a professional or group.

8.) KP: You’ve already woven several useful examples into the interview already, but could briefly walk me through your treatment process, perhaps by using a typical client scenario, so others can get a feel for how you work?

Diane: The thing about infertility is that it is a bit tough to generalize. It’s really case specific. I have patients as young as 32 years old who have premature ovarian failure, which is pretty devastating if you’ve been trying to get pregnant since you were thirty and you get this diagnosis that you’re coming to menopause at a young age.

Then I have patients of an advanced maternal age. Women who have been divorced, who have left a bad relationship, years go by, they work on their career and then they finally find a partner again. One of my clients just turned fifty and she trying to get pregnant using an egg donor with her wonderful partner that she finally found 4 years ago. So, she’s in a different place from somebody who is 32 years old.

Somebody in their late forties who knows that the only way they’re going to get pregnant and have a child is through egg donation has a different mindset. They may still grieve past losses but they are more readily able to move forward with a donor and they are perhaps more grateful that this option is available to them. Now, they have to deal with other issues, such as societal judgment about the “older parent,” although the mature parent is becoming more and more prevalent. The rise in women age 42-48 having children has increased 500% in the last five years. So, that’s a whole other arena in dealing with people’s emotions around “Is this natural?” “Will people judge me?” Dealing with the double standard around men being fathers at very advanced ages with younger women. But, this technology is available and egg donation is successful up to 75% of the time. So, that’s a very, very high number compared to when the doctor says you have a 2-3% chance of success with your own egg.

Back to your question about the treatment process, there are lots of different scenarios. Generally, people come to me when they’ve had at least one IVF or several miscarriages. They have experienced some pretty dramatic failure at this point. These would not be people who would be trying for 6 months and haven’t gotten pregnant.

They would come and see me, I would do an assessment and we would talk about their goals, we would talk about all the different options, whether it’s continuing IVF, moving to donor, adoption, using a surrogate, etc. I have had some patients with a genetic disease and they don’t want to pass it along, so the way they get around that is by using a healthy donor. Surrogacy, if that’s necessary, because sometimes it’s an egg issue, sometimes it’s a carrying issue, where the woman cannot hold a pregnancy. There’s also embryo donation. Parents who do conceive through IVF sometimes have leftover embryos. They have their one or two kids and they decide to donate their extra embryos. We talk about all the different options that might be available to them.

I like to work with the concept of some kind of timeline and milestones because it’s really, really critical for people going through this process to have milestones. We chunk it out into short, attainable goal, whether that’s changing clinics, or deciding to adopt, or whatever their next step. It means they need a plan for doing their homework, data gathering, how long things will take, etc.

We have a timeline, that includes goals around when is “enough” – when will they decide that they’re not going to keep pursuing one course and move to the next option, or coming to a point where they decide not to have children. Of course, you can’t decide all of that in the beginning, but I like to map out this framework for people in the beginning. This is helpful because I believe it reduces anxiety and gives people a sense of mastery over their destiny.

Usually, when a patient who has had fertility issues becomes pregnant, they want to stay working with me until they have that baby, because often times they have had multiple losses. I’ll work with them through the pregnancy and through the post-partum depression, because that’s very common for most women.

There are also major shifts in identity when they get pregnant and have their first child. This is something they have wanted so desperately for so long and then they get it and say “oh my gosh, be careful what you wish for” because you know, they’re sleep deprived, they can’t do their career as well…everything is turned upside down once they have their baby. So, I’ll help them work on these changes, the identity shifts, and the parenting issues they might face. I refer them to so many of the great resources that are in the San Francisco Bay Area for new parents. Usually, by then they’re on their way.

But, some people have really struggled for years. I have patients that have been dealing with infertility for 5+ years and they still don’t have a child one way or another and they continue to work with me. Hopefully, it’s not that long for most people, but it can be anywhere from 1 to 5 years before they’re able to somehow create their family.

KP: That’s great that you can provide that continuity of care when it’s needed. Once your client establishes that relationship with you, where you help them with the psychological and practical matters associated with infertility, you are able to help them through the next stages as well, with things like parenting issues or post-partum depression, if those arise.

9.) KP: How might your approach differ from other therapists that provide fertility counseling and coaching? I know that may be a hard question to answer.

Diane: I think that a lot of folks that are in this particular niche have had their own challenges with infertility. I don’t know exactly how they employ the different tools with clients, but I would say that for me, that deep sense of knowing about what that experience is like from an emotional perspective and also just the logistics of it all.

I think that my particular style is a plus. I tend to be interactive and collaborative and very empathic. I strive to build mutual trust and a very safe and non-judgmental environment.

I try to approach things with my own personal practices. I have been practicing meditation and yoga for twenty years now. I can’t believe it’s been that long, but it’s true! The compassion, the loving kindness, helping people to be more gentle with themselves and more forgiving. When people are struggling with infertility, they often blame themselves, saying “I waited too long, what was I thinking?” “My body is a failure!” So, just helping them to be really compassionate with themselves, to forgive themselves for any choices they have made in the past that seems to be connected with their current problem. Also, employing some of these practical tools that can help people during this particularly difficult period and also beyond. These are tools that they can use for the rest of their lives.

KP: In many respects, these clients you are seeing are going through a “crisis” so having practical tools that they can really hang onto and use right away can be so helpful. You are helping them with the internal pieces – the relaxation tools and self-compassion, for instance – and also providing them with some external guidance that you can be so helpful and provide a great deal of relief.

Diane: For clients, just knowing that there’s somebody they can talk to who really gets it, who understands every intricacy of their story. It just seems to be such a relief for people who can come in and talk about these things. For many patients, nobody in their life really understands what they’re going through, even their own partner sometimes doesn’t understand all of the frustration and challenges of dealing with infertility. Plus, partners grieve very differently.

KP: The importance of being understood and heard has almost, unfortunately, become cliché these days, but the fact remains that there tremendous power in that: really being understood and heard is quite healing. You having not only your professional expertise to draw on, but you’re able to relate on a personal level which, needless to say, is huge in terms of understanding.

10.) KP: Along those lines, can you share how you became interested in infertility counseling? I’m guessing that at least some of the interest came out of your own journey with infertility?

Diane: I have had a general counseling practice since 2000. Once I started in my own journey around 2004, I became very much involved in learning about it. I started joining professional organizations and got some additional training. I’ve done post-graduate study with ASRM (the American Society for Reproductive Medicine). Every year they have an annual conference and they offer great continuing education on all things fertility-related. As I’ve learned more about the field, I’ve continued my education, reading, finding more resources. I’ve just become fascinated with the field. It’s fast moving, it’s complex, it’s dynamic and it’s just a really exciting place to be.

KP: I can see how things would be so fast moving in this field, with the changing technology, awareness and lifestyle choices people are making. That’s great to hear that you are so connected to the professional community and actively involved in continuing education. For any therapist, staying up to date on the latest theories and techniques is so important, but certainly with a field that is so specialized and involves rapidly changing technology, it seems even more important.

11.) KP: I’m going to ask you a “softer” question now. What would you say is one of your greatest joys from your work?

Diane: I love helping people, it’s in my DNA. But, particularly in this field, with this kind of life altering experience, one of the greatest joys is helping my clients to reframe it, so that they can become more self aware and self-actualized as a person. That’s one of the greatest joys – to help them let go in ways that they never thought that they were capable of. And, also, of course, when a baby comes along, however, they come into the world.

It’s funny, some people will complete a course of counseling with me and then down the road I’ll get a call and they’ll say, “I just happen to be in the neighborhood” and they’ll want to show me their baby. It’s a really beautiful experience and I just feel so blessed and grateful that I’m able to help them achieve that dream.

KP: Absolutely! That must be an incredible feeling to be part of a process that is contributing to life. And, the other piece you mentioned really resonated with me — that life struggles present an opportunity not only just to get from point A to point B of becoming a parent, but looking at it as an opportunity to become more self aware, to grow. Essentially, that anything difficult and painful also presents a real opportunity, too.

KP: Anything else you want to add that we haven’t discussed today?

Diane: I would just really encourage other therapists and of course people in the wider community to seek out resources related to infertility. There are people who specialize in fertility counseling and sometimes other therapists aren’t even aware that this exists, so just to spread the word within the therapeutic community that there are resources out there and to refer. Even just for general, public, social discussion; somebody always has a story about trying to get pregnant or trying to adopt, so just being an advocate or voice for getting the word out there that there is help and there is support and people don’t have to suffer with this in isolation.

12.) Infertility Resources

I’ll repeat the resource information I provided earlier. The big one, an international organization that started in the United States and is the oldest fertility organization in the world, is called ASRM – the American Society for Reproductive Medicine [LINK: www.asrm.org]. That includes everybody – the medical side, the mental health side, the ethicists, lawyers, etc. Their website is very easy to use and you can find mental health practitioners there who are members on the ASRM site.

Resolve.org [LINK] as also been around for a long time, I think something like 30+ years. They’re not as medically focused as ASRM. Resolve is more of a support-group style organization for people in the community who are dealing with infertility. They also have local chapters where you can connect with a support group in your local area.

KP: Wow, this has been great! You know a lot!

Diane: I’m just so happy that I had the opportunity to do this. There’s a lot more we could have covered, but I think I’ve hit the major pieces and I’m grateful that we were able to have this conversation.

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These will be the Header questions (some are shortened versions of the actual questions posed) at the beginning of the document. Each question will link to the specific answer.

You are an expert in fertility counseling. Could you briefly explain what that is?

2.) Can you talk a bit more about the “issues around fertility?”

3.) It sounds like you also help clients by giving guidance or recommendations regarding medical treatment options for infertility?

4.) How might culture impact this whole process when it comes to dealing with infertility?

5.) While you provide general fertility counseling, you are also known as a specialist in “third party reproduction” in particular. Can you talk about that?

6.) Can you talk more about the specific tools you use when working with patients who are struggling with infertility?

7.) What is the greatest barrier to individuals or couples pursuing fertility counseling?

8.) Could you briefly walk me through your treatment process, perhaps by using a typical client scenario, so others can get a feel for how you work?

9.) How might your approach differ from other therapists that provide fertility counseling and coaching?

10.) Can you share how you became interested in infertility counseling? I’m guessing that at least some of the interest came out of your own journey with infertility?

11.) I’m going to ask you a “softer” question now. What would you say is one of your greatest joys from your work?

Infertility is a life crisis; an emotional, social, developmental, medical, ethical, and spiritual crisis. The medical definition is: “trying to conceive over a 12-month period without success.” These days, there are a higher percentage of people trying to conceive after age thirty-five. Thirty-five is when fertility starts to make a marked decline in women. Secondary infertility is defined as, “the inability to become pregnant, or to carry a pregnancy to term, following the birth of one or more biological children. The birth of the first child does not involve any assisted reproductive technologies or fertility medications.”

Psychological research shows that a diagnosis of infertility is as stressful as a diagnosis of cancer. People struggle, often quietly for years, with depression and anxiety due to their prolonged state of infertility. This leads to social isolation, which further exacerbates existing anxiety and depression. Because infertility is invisible, it can become a secret, which can lead to feelings of shame, guilt and personal failure.

The social aspect is often debilitating. Co-workers, friends, and relatives are pregnant, sending birth announcements and celebrating. Baby showers, children’s birthday parties and Facebook posts can be painful reminders of being left behind. This creates a social “in” and “out” group. These situations create a hyper-vigilant state of urgency around trying to catch up with peers and a desperate feeling that time is running out. Then there are the well-intentioned, yet typically uninformed questions, from those who want to be supportive but miss the mark.

What follows are my “best practices” in coping with the stress of infertility:

Do Your Homework. Initially, you may be overwhelmed with fear and disbelief. Try to stay calm so you can gather information about your options. If you have knowledge, it is power and it can settle down the feelings of uncertainty about your future. Review websites such as www.resolve.org and www.asrm.org since they are full of resources and factual data. Avoid infertility chat rooms. They are guaranteed to make you feel miserable and confused. If you haven’t already, make an appointment with a reproductive endocrinologist at a fertility clinic.

Feel Your Feelings. You will experience feelings akin to death and dying. Denial, “this isn’t happening to me!” Bargaining, “if only I’d… or, if only I hadn’t.” Grief, “I am incredibly sad, I cry all the time.” Anger, “I am so angry! Why is this happening to me?!” Acceptance, “I am accepting that this is my journey, I will get through this one way or another.” This cycle does not progress in a linear fashion. You can wake up one morning angry and be in denial the next. This is a normal response to loss and infertility is a big loss. You might not be able to have a child the way other people do. Your vision of the surprise moment when you tell your partner you’re pregnant, seems like a shattered dream. Other common emotions include envy, fear, guilt, shame, and confusion. Don’t stuff your feelings down. Talk to your partner, friends and family. Write in a journal. Seek professional help with a counselor who specializes in infertility counseling.

Focus On Self Care. It is extremely important to take extra good care of yourself during this stressful time. Eating a healthy diet will optimize your conditions for getting pregnant. Stay clear of processed foods and restaurants. Say goodbye to sugar, alcohol, dairy, caffeine and white flour for now. These foods cause inflammation in the body. Inflammation is the enemy of conception. Stay hydrated and get at least seven hours of sleep per night because sleep is incredibly healing. Engage in gentle exercise such as restorative yoga, walks, easy bike riding or swimming. Practicing deep breathing, meditation or prayer calms your central nervous system. See an acupuncturist who knows about infertility. Adopt a mindset of being in the moment. Don’t focus on regrets of the past or worries about the future. Repeat a soothing mantra such as “everything is going to be okay.” Give yourself a break and decline that invitation to another baby shower or birthday party.

Stay Connected To Safe & Trusted People. Share your story with friends and family who have the ability to listen, show empathy and not make judgments. Most are uninformed about infertility. Don’t take on the burden of trying to educate them. That is not your job, especially when you are struggling. Gently guide them to infertility resources so they can take on some of the responsibility of learning. It’s okay to say, “I don’t want to talk about it right now or I’ll let you know when I need an ear.”

Check In With Your Partner. Infertility is a couple’s problem and it can negatively impact your relationship. Unspoken resentment, feelings of inadequacy, and sexual pressure is not uncommon. Couples report increased conflict and decreased sexual relations due to invasive treatments and the impact of added hormones on mood stability. The financial strain takes its toll as well. Fertility treatments are costly with little to no insurance coverage provided. Seek out counseling for even a few sessions with a counselor who is knowledgeable about infertility. Attending fertility support groups or fertility weekend workshops can also be a great support.

Diane M, Coté, LCSW is a psychotherapist in private practice in San Mateo and San Francisco. She specializes in all things fertility related and mindfulness based practices. Her website link is: www.dianecotelcsw.com